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CZV7 /. ov I WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PEQMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS �.1 O A/v ` CITY/ZIP � Jam• L� � '57/� m <br /> /S`/� ' o <br /> CROSS STREET APN d O 5 � O _PARCEL SIZE�LAND USE APPLICATION# � <br /> OWNER NAME <br /> J Alf /`I"LL� PHONE CO-7 2-30 <br /> N <br /> C � <br /> OWNER ADDRESS ++ 1), L CITY/STATE/ZIP <br /> CONTRACTOR J— �/, ^ PHONE <br /> CONTRACTOR ADDRESS ` / <br /> CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP _ <br /> LICENSE 6WS7 1.0-61 D-09 I Other NUMBER, 73 — EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range___._ Section___ <br /> INTENDED USE Domestic/Private rrigation/Agricultural Industrial I Water Quality Monitoring a Soil Sampling/Characterization <br /> Public Water System_ <br /> If different from Owner: Water System Name Contact ame or one um er <br /> TYPE OF WORK ><ew Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) _ #of wells Soil Boring(s) #of borings Geotechnical #of borings <br /> gut-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> ew Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method-4. ud Rotary 1 Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depths f- ___ft Excavation ! in diameter Open Bottom > ravel Pack/Gravel Size_ in diameter <br /> I Gonductor Casing _in diameter / Conductor Casing Depth _ft <br /> Well Casing Diameter 6— in Thickness/Gauge/ASTM Schad i-i Steel ,blastic I Stainle s Steel Other_.__ <br /> Grout Seal Depth- 1F D ft I Neat Cement(94 lb bag/5-10 gal water) >Sllnd Cement ��_� sack mix/7 gal water <br /> I Bentonite(20%solids) I Other I <br /> Grout Placement Method ! Pumped 1 Free Fall Other I Retardant/Accelerator(name) <br /> PEDESTAL Installed By riller 1 Pump Contractor I Other <br /> i Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box '' Stove Pipe <br /> PUMP NdZubmersible Turbine Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT 11Y ^SQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINI M 2P HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL(209,)+953-7697 <br /> SIGNED TITLE �(�� - DATE L 0—f <br /> r <br /> IL <br /> 644 _�'p I <br /> i <br /> iA O <br /> Ho <br /> DEPARTMENT USE ONLY , l <br /> Application Accepted By Date 'L t) Area Employee ID# (SLcT,� <br /> Grout Inspectio y Date 141111A ❑ SPECIAL Well Permit <br /> Pump Inspection By J Date ❑ WAIVER Received <br /> Soil Boring Inspection B Date Constructed Well Depth ft <br /> COM ENTS r <br /> nacuti. , ` 14or r !Lv acct o Ffy 11T <br /> PE SC Received Check Amount Permit <br /> Codes Info B Remitted Date Service Request# Invoice# Well ID# <br /> L�3"&°l 73 3o3 U <br /> go os J 2 s3 IV 5_ 0'7330 <br /> ENC 43-06 WELL/PUMP PERMIT <br /> 4130/12 <br />